NOTE: The concept of this essay is described better in a 2009 Kilroy Cafe newsletter: TRIAGE: Doing what you can with what you have

For archive purposes, the original 2006 essay is retained below...

Issue #21, 9/26/2006

Triage

On the battlefield or during a natural disaster, there may be many more wounded than medical resources to treat them. If there are a hundred injured soldiers and only the personnel and supplies to treat ten of them, then some terrible decisions have to be made. Who do you treat, and who do you let die?

The process of sorting and selecting the wounded is called "triage." The goal is to save the maximum total number of lives, and this requires parcelling out resources in an often brutal way. The lightly wounded soldiers are probably going to be passed over, at least for now, because they will probably survive without treatment. The most gravely wounded soldiers might also be left alone, because they are likely to die no matter what you do. Furthermore, a massively wounded soldier is probably going to require huge resources that might save several others.

Who you end up treating in times of crisis are a certain middle class of "severe, but saveable" patients — those who would die without treatment but whose wounds require only moderate resources to repair.

You may see the word "Triage" at the first nurse's station you encounter in any big-city emergency room. This nurse takes your blood pressure, asks you some questions and makes a quick decision about your condition. They have the power to wheel you immediately into the trauma center or make you sit for hours in the waiting area.

Outside of emergency rooms, triage is a forgotten concept, but in fact it is a key component of any humanitarian effort. It is noble to want to "save the children," for example, but the question must then arise, "Which children?"

There is a delusion in modern society that every life is so valuable that you must pull out all the stops to save it. You see people do this with their pets: Little Fluffy is injured by a car. You get him to the vet and find out that, yes, Fluffy might be saved but it's going to cost $7,000. Fluffy is a member of the family; we can't just let him die, so we pay the $7k, and maybe it turns into $15k and Fluffy ends up dying anyway. Was it worth it? If not, when should we have pulled the plug?

We see the same thing with medically fragile infants, except that there is rarely any option to pull the plug. Every child is precious, and no one wants to see a child die, but some infants are just heading that way. Birth is always a dangerous event, a genetic and biological crapshoot. In past centuries, infant mortality was just a fact of life, but now that we have the medical means to keep more babies alive, it is hard to know where to stop. One million dollars? Two million dollars? Even if the child survives, he is likely to require huge medical resources throughout his life. If insurance won't pay, then one way or another the state picks up the tab, which essentially steals resources from other children who might be more treatable.

You often hear people say about some child welfare initiative, "As long as it saves even one child, then it's worth it." That's a fallacy. There will always be a practical limit to how much you should spend, and if you exceed that limit, you are implicitly denying resources to a more "saveable" child who is no less valuable.

Think of spending 15 grand to save Fluffy. Can you imagine how many human children you might save with the same funds at, say, a clinic in India? How many more children could you save—or, more importantly, whose whole lives you could improve—with the million dollars that might be spent to keep a single preemie alive in Nevada?

You may say India isn't relevant. We don't live there. Medicaid funds in Nevada can't be redirected to India. India isn't our problem.

Well, it's all part of the same system. ANYTIME you devote your resources to ANYTHING, you are implicitly redirecting those resources away from something else. Four bucks spent on a latte at Starbucks is four bucks you could have given to some worthy cause that could get a lot more mileage out of it.

Almost every decision you make is a triage decision. Time, money, attention, creativity — whatever resources you may have, you are making a decision of god-like importance when you spend them. You may be helping children by giving to Jerry's Kids, but at the same time you are hurting others by not addressing, say, child poverty in Mexico. Everything is a tradeoff.

You can't win. That's what you've got to remember. In whatever humanitarian field you choose, you are never going to win. Child welfare is an unwinnable war. Drug abuse is an unwinnable war. Even medical research is an unwinnable war, because to cure a disease, you usually must redirect valuable resources from other worthy causes. Furthermore, you will probably create new social problems simply by virtue of keeping more people alive. (Look at India.)

The best that any of us can do is make sound, rational triage decisions concerning the few resources we actually control, maximizing as best we can their total benefit to humanity. This is not easy and never will be.

Fluffy, no matter how much he means to the family, isn't worth $15,000 — not in the grand scheme of the planet. How much is he worth? Where should you stop? That's the big question.

It's a terrible, brutal, horrible decision, but it has to be made every day, in everything you do. It may not be obvious to you that there are a hundred children who need your attention, but they are there, probably right in your own neighborhood, and you're leading a fat and happy life, drinking your latte, only because they happen to be invisible to you at the moment.

To make the right triage decisions, you have to be aware that there is suffering all around you. You just have to open your eyes. Then, when you recognize how terrible life is for so many people, you might achieve some humility and spend your resources more thoughtfully.

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